The key principles for after hours primary health care services.

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1 RDAA SUBMISSION TO THE REVIEW OF AFTER HOURS PRIMARY HEALTH SERVICES Introduction RDAA believes that arrangements for after hours primary health care services must be reviewed and revised. Feedback from members indicates that there has been widespread dissatisfaction with the current arrangements since responsibility for after hours services was devolved to Medicare Locals in July We are concerned about the short time frames under which the review is operating. This has the potential to limit stakeholder input as it is often difficult for small organisations in particular to consult with their members and to develop meaningful responses to the key themes under which the review is to be conducted. RDAA maintains its opposition to the decision to abolish after hours Practice Incentive Payment (PIP) and devolve responsibility for funding after-hours after hours services to Medicare Locals. We support a return to the national administration of after hours payments and incentives through the PIP. This could be complemented by regionally based programs with specific funding to identify and address service deficits and gaps. The key principles for after hours primary health care services. RDAA recommends the following key principles to underpin after hours primary health care services: After hours incentives and payments should be administered in a consistent and transparent manner that maximises administrative efficiency and minimises administrative imposts on doctors and practices. All GPs who have the appropriate skills, qualifications and experience should have the opportunity to provide after hours services. All funds allocated for after hours services should be returned directly to the practices providing this care rather than through an administrative agency which requires additional funding. Existing activity and service delivery at rural hospitals should be maintained to avoid negatively impacting on the sustainability of these facilities, their funding and their staff skill sets. Arrangements should have no influence or impact on existing State industrial arrangements with respect to the provision of after hours services from public hospitals where these arrangements do not involve any Federal funding. Arrangements should not create the potential for cost shifting from State Governments to the Federal Government. Hourly rates should reflect current industrial arrangements with the States and there should be a minimum number of hours for which hourly rates are paid. Funding of after hours arrangements outside hospital Emergency Departments should not be restricted to bulk billed consultations. The role of General Practitioners and general practice in delivering after hours services. RDAA supports the need for continuity of patient care, including after hours primary care. This is especially important in rural areas and it is best based within the general practice setting.! 1

2 Delivery challenges of after hours primary health care services in rural and remote regions. Rural practice is unique in that rural General Practitioners (GPs) usually provide a range of services, including primary care, acute care and after hours and emergency services, in both the general practice and hospital setting. They also work in both Federal and State jurisdictions. After hours services form one component of the total picture of rural practice, where each component has the potential to impact on the way in which other services can be provided. A large number of rural and remote practices are small practices dispersed across geographically isolated areas. They are vulnerable because they are inherently unstable and have little internal stability or redundancy for support. 1 It costs more to run a rural practice of any description and there is a reduced capital gain on any investment by rural doctors in practice infrastructure compared with urban practice. Rural practices often lack the capacity to be able to adapt their business models to respond quickly to changing market circumstances. A recent study provides evidence that a GP s total hours worked per week consistently increases as community size decreases. 2 These differences are linked to the work rural GPs undertake in public hospitals. The study also concluded that GPs working in smaller rural communities also have a higher on call workload, with the likelihood of a GP attending more than one call out a week ranging from 9% for urban GPs up to 48-58% for rural GPs in small communities. 3 After hours care is an essential component of rural practice and a vital service to people living in rural and remote communities. Removal of after hours care funding to any degree threatens after hours access for large areas of rural Australia where patients have no alternatives to medical care. There is no local fully staffed Emergency Department to provide an alternative. If patients present to the local hospital for care, they are often treated by the same doctor who they would generally visit in the private practice. The foundations of after hours services in many rural communities are fragile, resting on the goodwill of an ageing workforce of GPs who are committed to doing the right thing by their communities. In the past these doctors have tirelessly provided after hours services and often make considerable lifestyle sacrifices to do so. As members of this ageing workforce retire, they are being increasingly replaced by a medical workforce which is generally less inclined to make the lifestyle sacrifices associated with providing after hour services, especially in the absence of significant financial compensation. The personal costs associated with working longer hours and having an on-call workload, particularly in the absence of adequate rewards and supports, impact on the professional satisfaction of rural doctors. In the face of these challenges, many rural practices are simply struggling to remain professionally and financially viable. Rural practices must also balance meeting the after hours health care needs of their communities with the need to provide a safe workplace, reasonable working hours and adequate remuneration. Small rural practices find it difficult to provide cover internally when!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 1 Monash University School of Rural Health and the Rural Doctors Association of Australia (2003) Viable Models of Rural and Remote Practice. Stage 1 and Stage 2 Report; at page XVII. 2 McGrail, MR, Humphreys, JS, Joyce, CM, Scott, A, and Kalb, G. How do rural GPs s workloads and work activities differ with community size compared to metropolitan practice? Australian Journal of Primary Health, November 2011, published online at 3 Ibid.! 2

3 one doctor is on leave, particularly where these practices provide after hours and emergency care at the local hospital and the on call rates are very high. If the level of funding support provided to rural GPs who provide after hours services comes under threat, there is an increased risk that rural GPs will simply walk away from providing after hours services. The financial viability of rural practices may be undermined by the withdrawal of this income. If practices become unviable, this jeopardises not only general practice based primary care, but also services which can be provided at rural hospitals. Experience/views on the Practice Incentive Program (PIP) after hours incentive. The PIP after hours incentive provided a transparent, consistent national process for delivering the after hours incentive to eligible general practices that provide after hours services. Because it was a national system and based on Medicare billings, administrative costs were kept to a minimum, as were the administrative imposts on practices. Practices were provided with certainty in that they knew what income they would receive from the PIP, and when. These principles of consistency, transparency and cost efficiency should underpin arrangements for after hours incentive payments in the future. RDAA supports the retention of after hours services as a separate component of the PIP, rather than combining these payments as part of a blended payment model. Experience/views with Medicare Locals being responsible for funding and incentivising after hours primary health care services. RDAA has previously voiced its concerns about the capacity of Medicare Locals to take over responsibility for planning, coordinating and funding after hours services, particularly in rural and remote communities. While Medicare Locals were very effective in some areas, their performance nationally was extremely variable. For many rural practices, dialogue with Medicare Locals about the new after hours funding arrangements was marked by uncertainty, poor communication, and last minute and heavyhanded negotiations, all of which generated a significant amount of angst (both personal and financial) for doctors and practices. The initial after hours funding contracts were unnecessarily onerous. Following protests by a number of stakeholder organisations, these were subsequently withdrawn and revised. However, the new contract template only became available three weeks before the implementation of the new arrangements, and after practice staff had spent considerable time and money going through the initial contracts and seeking legal advice. This generated even more frustration. A common complaint from members was that many Medicare Local staff did not appear to understand the structure of rural practice and the myriad of different service delivery models for effective after hours care that have been developed over time to suit the needs of rural communities. For example, in some cases Medicare Locals did not recognise existing rural after hours services as working well on the basis that they did not adhere to a rigid interpretation of the guidelines for funding after hours arrangements (ie the service was not operated as a clinic that was open to anyone who walked in off the street). In some smaller rural! 3

4 communities, this service delivery model was not viable on a number of levels and posed a risk to doctors who may well end up working alone at night in the practice. There was potential for conflicts of interest where the Medicare Local was both a fund holder and a service provider, or where members of the Medicare Local board were involved in the provision of after hours services. RDAA members also expressed concern about the overall increased administrative imposts on practices and the amount of funding which was taken up by operational and administrative procedures. Potential future arrangements for funding and incentivising after hours primary health care services, including advantages and disadvantages of potential options and their relevance to rural and remote regions. While the majority of practices that previously received PIP payments for after hours services eventually signed short term contracts with Medicare Locals, the process has left many rural doctors and rural practices somewhat disillusioned. As a result, many rural doctors will be cautious about another new regime, and there will be no second chances in terms of engaging with rural doctors and gaining their confidence and long term support. For this reason, any new arrangements will need to prioritise meaningful engagement with GPs and practices and include robust communication and consultation mechanisms. Evaluation of the new arrangements should be timely and should include opportunities for input from both providers and consumers of after hours services. New arrangements should be based on a model which rewards doctors and practices that are providing appropriate services to their communities. They must recognise the remoteness and general working environment of many of the areas in which these services are provided, bearing in mind that after hours services is one component of the integrated delivery of health services in rural areas. They should also aim to reduce administrative imposts on rural doctors and rural practices and support after hours arrangements which have been working effectively over a long period of time.! In terms of future arrangements, RDAA strongly supports a return to the after hours PIP. There may still be a need to address service gaps and market failure in some areas. If this is the case, then these functions could be devolved to Primary Health Networks or other regionally-based organisations and funded on a project basis. Experience/views on after hours GP helpline. RDAA believes the minimum credentialing requirement for GPs staffing the after hours helpline should be FRACGP or FACCRM. The award of these qualifications certifies competence to deliver unsupervised general practice services in any general practice setting in Australia. Any standard less than this is unacceptable. Many parts of rural, regional and remote Australia do not have access to information technology services, especially after hours. The capacity to communicate appropriately with many providers is still limited and this may continue into the future. This means that, when a patient accesses advice from the GP helpline, his regular GP may not be notified of the consultation, or there may be difficulties in providing an electronic copy of the advice for follow-up care.! 4

5 Given the importance of providing face-to-face care in rural areas, RDAA would oppose the allocation of additional funds to the GP helpline, especially if this funding were to be provided at the expenses of on-ground after hours services. Experience/views on using video conferencing for after hours primary health care services. Videoconferencing and telehealth consultations can provide valuable support mechanisms for general practitioners in rural areas but they can never replace face-to-face consultations, and should not be viewed as an alternative model of treatment. Any other information/comments. Industrial Arrangements: Any new after hours arrangements should not impact on existing State-based industrial agreements under which doctors provide after hours services at local hospitals. This is particularly important in rural areas where GPs provide services to State jurisdictions either on a Visiting Medical Officer (VMO) basis, or through other salaried arrangements. RDAA urges the Department of Health and Ageing to engage with the State Health Departments to ensure the continuation of State-based industrial agreements under which doctors provide after hours services through local hospitals. Potential for Cost-Shifting: RDAA has concerns regarding the ongoing cost-shifting that occurs from State Governments to the Federal Government with respect to the provision of after hours primary care services from State-funded public hospitals. The nature of these agreements varies from State to State. For example in Victoria, hospitals with designated Emergency Departments will usually have junior medical staff who see patients initially and then VMO on call who will be funded by the hospital if they see a patient at the request of the junior staff. However smaller hospitals without designated Emergency Departments usually rely on the GP VMOs to bill Medicare when seeing patients who present for urgent care - with the subsequent issues of accepting a discounted Medicare rebate as full payment or trying to chase private billings, especially difficult if patients expect not to pay anything for emergency presentations to hospital. This is especially difficult if the doctor has to leave their private practice (and private patients) to attend an "emergency" at the hospital- the same person who might not be willing to wait for, or pay for a visit at the practice. There are similar situations in some other States, where rural GPs are expected to bill Medicare for primary-care after hours consultations which take place at the local hospital. In some cases this practice may be contrary to the Australian Health Care Agreement. This situation needs to be addressed.!!!! 5